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# Diabetic ketoacidosis

Diabetic ketoacidosis is a diabetes emergency: without insulin the body burns fat out of control and the blood turns acidic.

Updated 2026-10-31

## Structures involved

Tap one to see what it is and open it in 3D.

- [Pancreas](https://durgical.com/en/anatomy/pancreas/)
- [Liver](https://durgical.com/en/anatomy/liver/)
- [Kidneys](https://durgical.com/en/anatomy/kidney/)
- [Stomach](https://durgical.com/en/anatomy/stomach/)

## In biochemistry

- [Ketogenesis: Step 4 · β-Hydroxybutyrate dehydrogenase (BDH1)](https://durgical.com/en/biochemistry/pathways/ketogenesis/#paso-4)
- [Glucogenic and ketogenic amino acids](https://durgical.com/en/biochemistry/topics/glucogenic-and-ketogenic-amino-acids/)
- [Acetyl-CoA](https://durgical.com/en/biochemistry/molecules/acetyl-coa/)
- [Acid–base interpretation (step by step)](https://durgical.com/en/biochemistry/topics/acid-base-interpretation/)
- [Anion gap and delta ratio](https://durgical.com/en/biochemistry/topics/anion-gap-and-delta-ratio/)
- [Urinalysis](https://durgical.com/en/biochemistry/topics/urinalysis/)
- [Mitochondrial HMG-CoA synthase (HMGCS2)](https://durgical.com/en/biochemistry/enzymes/mitochondrial-hmg-coa-synthase/)
- [β-Hydroxybutyrate dehydrogenase (BDH1)](https://durgical.com/en/biochemistry/enzymes/hydroxybutyrate-dehydrogenase/)
- [Succinyl-CoA:3-ketoacid CoA transferase (SCOT)](https://durgical.com/en/biochemistry/enzymes/succinyl-coa-3-ketoacid-coa-transferase/)
- [Hormone-sensitive lipase (HSL)](https://durgical.com/en/biochemistry/enzymes/hormone-sensitive-lipase/)
- [Acetoacetate (acetoacetic acid)](https://durgical.com/en/biochemistry/molecules/acetoacetate/)
- [β-Hydroxybutyrate](https://durgical.com/en/biochemistry/molecules/hydroxybutyrate/)
- [pH, buffers and the Henderson–Hasselbalch equation](https://durgical.com/en/biochemistry/topics/ph-buffers-and-the-henderson-hasselbalch-equation/)
- [Fed, fasting and starvation states](https://durgical.com/en/biochemistry/topics/fed-fasting-and-starvation-states/)
- [Insulin signalling](https://durgical.com/en/biochemistry/topics/insulin-signalling/)
- [Glucagon signalling](https://durgical.com/en/biochemistry/topics/glucagon-signalling/)

## Microorganisms that cause it

- [Mucorales (Rhizopus, Mucor)](https://durgical.com/en/microbiology/mucorales/)

## In the clinical exam

- [Respiratory rate and breathing patterns](https://durgical.com/en/clinical-exam/respiratory-rate-and-breathing-patterns/)

## In physiology

- [Osmosis, osmolarity and tonicity](https://durgical.com/en/physiology/osmosis-osmolarity-and-tonicity/)
- [Physiology of diabetes and ketoacidosis](https://durgical.com/en/physiology/physiology-of-diabetes-and-ketoacidosis/)
- [Glucagon and the counter-regulatory hormones](https://durgical.com/en/physiology/glucagon-and-the-counter-regulatory-hormones/)
- [Fed and fasting states: the hormonal switch](https://durgical.com/en/physiology/fed-and-fasting-states-the-hormonal-switch/)
- [Potassium balance](https://durgical.com/en/physiology/potassium-balance/)
- [Reading an arterial blood gas step by step](https://durgical.com/en/physiology/reading-an-arterial-blood-gas-step-by-step/)
- [Metabolic acidosis, the anion gap and compensation](https://durgical.com/en/physiology/metabolic-acidosis-the-anion-gap-and-compensation/)
- [Glucose transport maximum and renal threshold](https://durgical.com/en/physiology/glucose-transport-maximum-and-renal-threshold/)
- [Mixed acid–base disorders](https://durgical.com/en/physiology/mixed-acid-base-disorders/)
- [Control of breathing, chemoreceptors and lung reflexes](https://durgical.com/en/physiology/control-of-breathing-chemoreceptors-and-lung-reflexes/)
- [Abnormal breathing patterns and sleep apnea](https://durgical.com/en/physiology/abnormal-breathing-patterns-and-sleep-apnea/)

## What it is

An acute complication of insulin lack with excess counter-regulatory hormones: high glucose, high ketone bodies and high anion gap metabolic acidosis.

## Who gets it

It is most common in type 1 diabetes and may be its first sign, especially in children; it also occurs in type 2 with severe stress and with SGLT2 inhibitors (sometimes with near-normal glucose).

## Causes

- Undiagnosed type 1 diabetes
- Stopping or lacking access to insulin
- Infections, heart attack, pancreatitis, pregnancy
- SGLT2 inhibitors (euglycemic ketoacidosis)

## Risk factors

- Type 1 diabetes, especially in teenagers
- Financial barriers to buying insulin
- A malfunctioning insulin pump

## Pathophysiology

Without insulin, fat releases fatty acids that the [liver](https://durgical.com/en/anatomy/liver/) oxidises to acetyl-CoA. Glucagon diverts oxaloacetate to gluconeogenesis, so acetyl-CoA cannot enter the Krebs cycle and becomes acetoacetate and β-hydroxybutyrate. These acids use up bicarbonate; high glucose causes osmotic diuresis, dehydration and potassium loss.

## Classification

- Mild, moderate or severe by pH, bicarbonate and mental state
- Euglycemic: glucose below 250 mg/dL (SGLT2, pregnancy, fasting)

## Symptoms and signs

- Intense thirst and passing a lot of urine
- Nausea, vomiting and abdominal pain
- Deep, fast breathing (Kussmaul) and fruity breath
- Drowsiness or confusion

## Red flags

- Altered consciousness or coma
- Headache or neurological decline during treatment in children (cerebral edema)
- Low potassium before starting insulin

## Diagnosis

**Clinical**
Known or suspected diabetes with dehydration, vomiting and Kussmaul breathing.

**Tests**
Glucose (usually high), blood β-hydroxybutyrate or urine ketones, blood gases (low pH, low bicarbonate), anion gap, potassium, sodium, [kidney](https://durgical.com/en/anatomy/kidney/) tests; look for the trigger (cultures, ECG, troponin, lipase).

**Imaging**
[Chest](https://durgical.com/en/anatomy/region/chest/) X-ray if infection is suspected; brain CT if neurological decline occurs.

## Treatment

**Acute**
Intravenous fluids to correct dehydration

**Acute**
Intravenous insulin infusion, after checking that potassium is not low

**Medical**
Potassium replacement and treatment of the trigger

**Follow-up**
Glucose, potassium, blood gases and ketones at short intervals until it resolves

## Complications

- Low potassium and low glucose during treatment
- Cerebral edema (mainly in children)
- Acute kidney injury

## Prevention

- 'Sick day' education: do not stop insulin, check ketones
- Uninterrupted access to insulin

## Test yourself

Think of the answer, then tap the question to see it.

## Why does acetyl-CoA become ketone bodies in ketoacidosis?

Oxaloacetate is diverted to gluconeogenesis, so acetyl-CoA cannot enter the Krebs cycle.

## Which electrolyte is checked before starting insulin?

Potassium: insulin drives it into cells and can drop it dangerously.

## Which drugs can cause ketoacidosis with near-normal glucose?

SGLT2 inhibitors (gliflozins).

[Add to my cards (3)](https://durgical.app/estudiar/?add=/en/conditions/diabetic-ketoacidosis/)

## Related conditions

- [Type 1 diabetes mellitus](https://durgical.com/en/conditions/type-1-diabetes-mellitus/)
- [Type 2 diabetes mellitus](https://durgical.com/en/conditions/type-2-diabetes-mellitus/)
- [Lactic acidosis](https://durgical.com/en/conditions/lactic-acidosis/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Diabetic ketoacidosis: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000320.htm) (MedlinePlus, US National Library of Medicine, 2026); [Diabetes](https://www.who.int/news-room/fact-sheets/detail/diabetes) (World Health Organization, 2026); Textbook of Biochemistry for Medical Students, 6th ed. (Jaypee Brothers Medical Publishers (Vasudevan DM, Sreekumari S, Vaidyanathan K), 2011).

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Source: https://durgical.com/en/conditions/diabetic-ketoacidosis/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/diabetic-ketoacidosis/